Murray County Schools

MURRAY COUNTY SCHOOLS

FIELD TRIP, COMPETITION, PERFORMANCE,

APPLICATION FORM

School: Date of request:

Name of class or group:

Destination: / Month / S / M / T / W / T / F / S / Year
Day of Week

Departure time:______Return time:______# of participating students:______

Supervisors/Teachers:______

______

Overnight field trips require a ratio of adults to students as follows:

Elementary 1/15 Middle 1/20 High 1/25

Chaperone list must be attached (all non-system employees must have background check, see chaperone page)

Have all students in the class/group/team been given opportunity to take part in this field trip?

Type & number of vehicles requested:______

What special accommodations for handicapped students are needed?

Name of Bus Driver/Sponsor that will be driving:___

Note: drivers must be on approved list of drivers at Transportation Dept.

If Competition please check

Define Competition:

Cost of field trip:

Miles round trip:______x $1.50 per mile =______

Driver cost: $10.00 per hour with 4 hour minimum. ______

Approximate cost of trip:______Student Fees/Donations: $______

Who is responsible for the bill?

Note: A $25.00 charge will apply if bus or buses are returned unclean. (Ex. drink spills, trash left on floor, etc.)

Signature of teacher in charge: Date:

Print Name of teacher in charge:______

 I have notified Food Service.  Students have parental approval.

 I have made arrangements for a substitute teacher, if necessary.

Signature of Cafeteria Manager: Date:

Approval of Principal: Date:

MURRAY COUNTY SCHOOLS

Field Trip Curriculum

STANDARDS: (i.e. S2P3, M6D1a) ______

BIG IDEAS: (i.e. Give a brief description of how the standards listed above are being demonstrated through the field trip experience.)

PRE-WORK: (i.e. Describe in some detail how students have been prepared for the field trip. Students read Island of the Blue Dolphin and researched the history and geography of Savannah before the field trip. This description must support the standards above.)

FIELD TRIP ACTIVITIES: (i.e. Describe learning activities for students both on the bus and at the site of the field trip. These activities must support the standards above.)

POST-WORK: (i.e. Describe how teacher will assess students’ increased understandings of the above standards after the field trip.)

PLEASE NOTE: (1) The office of Curriculum will adhere strictly to the Murray County policy & guidelines to insure instructional integrity for all students. (2) The supervising teacher must have each student’s emergency information in his/her possession during the field trip.
(3) Employees and adult supervisors must refrain from personal practices which would be inconsistent with their responsibilities to supervise students throughout the entire field trip.
(4) This form must be received by the appropriate Central Office administrator at least 4 weeks prior to approval/denial of the trip request. KEEP A COPY OF THIS COMPLETED FORM FOR YOUR INFORMATION

AUTHORIZATION TO RELEASE CRIMINAL INFORMATION FORM

FOR PARENT CHAPERONES AND OTHER VOLUNTEERS

1.  I hereby authorize any law enforcement agency to give to the representative of the Murray County Board of Education any and all information in their possession regarding any criminal history or record or other information pertaining to me, which may be on file with any criminal justice agency. I also agree to be fingerprinted by the appropriate officials if asked.

2.  I also consent to the release of such information to the Murray County Board of Education now and at any time during my association and hereby release, discharge, and waive any and all claims, which may arise from the release of accurate information.

3.  This release is executed with full knowledge and understanding that the information is for the official use of the Murray County Board of Education, its agents and assigns, only.

4.  I am furnishing my social security number and other personal data on a voluntary basis with the understanding that it will be utilized to facilitate the location of any criminal information concerning me.

5.  I understand that I may be disqualified from approval as a chaperone or volunteer as a result of information received regarding my criminal history.

6.  I understand that any information received regarding my criminal history will be kept confidential, and shared only with those who have a need to know.

7.  The criteria for determining that an individual is disqualified from acting as a chaperone/volunteer is a conviction for:

·  Any violent felony within the last 15 years

·  Any drug felony within the last 5 years

·  Any violent offense toward a minor at any time

·  Any offense of a sexual nature at any time

·  Any other offense that may give reasonable justification

·  Note that “conviction” refers to any finding or other than Nolo Prossed, Dismissed, or Not Guilty.

NAME: (Printed)

Last, First, Middle

Address/Street

City, State, Zip Code

Sex Race Date of Birth Social Security #

____________

Height Weight Eye Color Hair Color State of Birth

My signature affirms that I have read and understand the information above and that any and all information provided by me is accurate to the best of my knowledge.

Signature Date

LIST OF PARENT / VOLUNTEER CHAPERONES FOR OVERNIGHT FIELDTRIPS

This form must accompany all applications for overnight field trips.

Group: ______Trip to: ______Departing on: ______

The purpose of this form is to assist in insuring that all parent / volunteer chaperones attending overnight field trips have undergone a criminal background check per BOE policy.

·  Anyone attending an overnight school-sponsored trip that may potentially supervise a student (other than their own child) is to be considered a parent / volunteer chaperone. An updated list of approved parent / volunteer chaperones will be available in the principal’s office at each school.

·  In the spaces below list the names of all parent/volunteer chaperones that plan on attending the trip unless they are current Murray County School System employees. (Active substitutes are considered employees.)

·  Check the names against the list of APPROVED parent / volunteer chaperones in the PRINCIPAL’S OFFICE. For those who ARE on the approved list, record the Clearance Number in the space provided below.

·  For those who ARE NOT on the list, please attach a completed “Authorization to Release Criminal Information” form and write “yes” in the appropriate column.

·  Your principal will be notified if there is a problem.

Name of Parent / Volunteer Chaperone / Clearance # / OR / “YES” if an Authorization
Form is Attached

____ There are no chaperones attending this trip who are not employees of the Murray County School System.

Trip Organizer’s Signature: ______

Exhibit 3

FIELD TRIP PERMISSION FORM

Teacher name: ______

School name: ______

GENERAL INFORMATION

Destination site:______

Date of trip:______Departure time:______Return time:______

This field trip is available to all students regardless of the ability of the parent/guardian to donate funds in support of the field trip. Trips may be canceled if sufficient funds are not obtained. When school is closed for inclement weather, field trips are canceled or postponed. Parents who are unable to contribute toward the cost of the field trip should contact the school principal.

Note: When parents and students volunteer to drive their own vehicles on school system business, such as sporting events, field trips, or other school activities, the Murray County School District does not provide liability insurance nor medical insurance coverage for the volunteer, should he/she be involved in an accident; the volunteer is the liable party.

………………………………………………………………………………………………………

PERMISSION

I certify that my child, ______, has my permission to participate in the field trip described above.

Signature of parent/guardian: ______Date ______

EMERGENCY CONTACT

Name: ______Phone#:______

Note to parent/guardian: Please indicate any medical needs which your child has for adult supervisors to be aware.

______

______

PLEASE RETURN THIS FORM NO LATER THAN______

Date

Failure to return this form by the specified date may exclude your child from the field trip.

PARENT/GUARDIAN

MEDICAL AUTHORIZATION FORM

If any medical or operative procedure ever becomes necessary, every attempt will be made to contact you prior to the institution of any therapy. On rare occasions it may be necessary to proceed in an emergency situation before you can be reached. Should this occur, we must have a signed authorization form allowing us to do so. This form will permit us to render the emergency care you would rightfully expect of us. Please fill in the requested information below, sign, and return this form immediately.

______, ______

Student’s Last Name First Name Middle Name

Permission is hereby granted to the Murray County School System to proceed with any needed medical or minor treatment, x-ray examination, and immunization for the above named student. In the event of serious illness, the need for major surgery, or significant accidental injury, I fully understand that an attempt will be made by the attending physician to contact me in the most expeditious manner possible. If said physician is unable to communicate with me, the treatment necessary for the best interest of the above named student may be given.

______

Signature of Parent/Guardian Relationship to Student

______/ ______/ ______

Date